San Francisco Drug Users Face Soaring Deaths. Solidarity Can Sustain Us.

    My stomach was churning frantically as I lay strapped to a gurney in San Francisco General Hospital that day in 1992. Someone who looked like a police officer or a security guard walked back and forth past my bed. I was forced to wait an hour until they released me from restraints and I could sign myself out AMA—against medical advice. I was told I had been given a drug called Narcan.

    While I was grateful to be alive, waking up surrounded by EMTs and police was frightening. I was told police frequently came along with EMTs after 911 calls to “chaotic” sites, like the hotel where I was living at the time. The police directed the EMTs to take me to the hospital, even though I was awake and alert. They told me that if I refused, they would take me to jail for possession. In this case, it would have been for possession of a single now-empty syringe.

    I was terrified. I knew that if they carried out that threat, I would sit dopesick in jail for days until my case was eventually dismissed. It felt like cruel and unusual punishment for what was, essentially, a medical emergency. That experience forever molded my perspective on overdose. That, and the $500 hospital bill I later received from a collections agency.

    All these interventions are crippled in a pandemic.

    San Francisco is currently on track to lose upwards of a 675 people to overdose in 2020—a grim record. By August, the city had already surpassed the 441 lives lost in 2019.

    While the city has over the years expanded access to naloxone (Narcan) and low-threshold buprenorphine, added bedside addiction services in hospitals and expanded street outreach, all these interventions are crippled in a pandemic.

    People who use drugs, who have long been cautioned to never use alone, are now being instructed to isolate—and naloxone only works when there is another person there to administer it. City-based supportive housing programs currently allow no visitors. For every step forward, we are now experiencing many more steps back.


    A Long Fight for a Community Taking Care of Its Own

    Throughout the 1990s, overdose became my constant companion. In 1998, fresh out of rehab, I was browsing the paper when one article caught my eye—San Francisco was in the midst of an “overdose crisis.” Names of recent victims of accidental heroin overdose were listed. One in particular stood out to me: Jennifer. She had been my partner a few years prior to my 1996 incarceration, and was the sweet woman who wrote me letters with hearts on the envelopes when I was in jail.

    We had no naloxone or other tools—just running to call 911 from payphones.

    Working as a peer counselor at the time, I wondered what I could do to help. I thought back to how, when I was still using drugs, we would warn each other about bad batches while standing in line at the syringe exchange. By the time I got sober in 1998 I had saved five of my friends from overdose. We had no naloxone or other tools—just running to call 911 from payphones and a week of CPR training from my high school days. But there was, and will always be, a community of folks that care for their own. We gave each other hope.

    Treatment options were limited in the ’90s. The two dominant modalities were abstinence-based and/or attack therapy—where counselors “break you down to build you back up.” Wait lists for methadone clinics were long, and you had to have a minimum of two “failed” treatment episodes in detox slots before methadone was even available as an option.

    Housing, too, was limited. There was a sense of despair among people who used drugs, many of whom were still being disproportionately impacted by the AIDS crisis. From 1997 to 2000, 47 percent of all heroin-involved overdoses in San Francisco occurred in low-income residential hotels; 36 percent occurred in one small central area of the city. In 68 percent of fatal overdoses, the victim was reportedly alone.

    In 1999, I was encouraged to join what was then known as the city’s “heroin committee.” I sat around the table with doctors, public health professionals, advocates and activists. We were united in our frustration. While our friends continued to die, we were tasked with creating solutions. Out of this work were born: the Harm Reduction Policy for San Francisco, the Treatment on Demand workgroup, the “Fix with a friend” campaign, and later the DOPE Project, where I worked part-time until 2007. We began teaching rescue breathing and providing harm reduction education to people who were using drugs.

    I heard Dan Bigg recommend that we should be diverting services away from the police and putting naloxone directly into the hands of people who needed it.

    In January 2000, I attended a conference in Seattle, Washington, on preventing heroin overdoses. Because I was still in a very rigorous 12-step-based recovery program, and on probation, I was afraid to travel outside my room at a sober living facility in the Tenderloin. I was afraid of what impact this work might have on my own abstinence. What I found was that it expanded my world.

    At the conference, I heard Dan Bigg recommend that we should be diverting services away from the police and putting naloxone directly into the hands of people who needed it most. By 2003, naloxone distribution began in San Francisco. In 2013, I was encouraged to begin sending naloxone through the mail by people I met through social media.

    The mentality of the work had traveled from the city far into the suburbs and rural areas, but the resources had not always traveled with it. While I had access to this life-saving medication, the people who reached out to me still did not.


    Scarce Resources Meet New Threats

    The more things change, the more they seem to stay the same. Despite some progress over the years, the introduction of fentanyl into the drug supply around 2013 brought on an overdose crisis that dwarfs the previous one. San Francisco’s 450 overdose deaths in the first eight months of 2020 were more than double the annual number that was considered a crisis in 1998.

    We are still struggling under many of the same antiquated systems that harm us instead of help us. Resources flow through federal, state and local entities that often only see harm reduction as a vehicle for the promotion of abstinence-based recovery. Access has expanded, but so has need.

    Many harm reductionists are left to turn to corners of the internet to try to scrounge up test strips, syringes, the meth and crack pipes that many of our county programs won’t let us purchase, and more naloxone (even the expired kind—it can still remain effective for another year or two).

    We have mail-based programs through the hub at NEXT Distro with limited or no funding for postage. We have syringe exchange programs in more locations, but they’re often limited to one-to-one exchanges. We have the US Surgeon General promoting naloxone in a public health campaign, but no real significant federal funding for our on-the-ground work.

    I am proud of how far we have come. Yet the road to liberation seems to be getting longer and longer.

    The structural threats that we faced in the 1990s remain deeply entrenched. We still fight against white supremacy, denial of bodily autonomy for sex workers, homophobia and hate and violence against trans people, the drug war, evictions, and child “welfare” systems that extract children from homes based on prejudice and arbitrary rules.

    I am proud of how far we have come. Naloxone is now a mainstream word. Drug decriminalization in Oregon is leading the way forward. The legalization of cannabis is gaining momentum every day. We have a national discourse on safe consumption sites. Yet the road to liberation seems to be getting longer and longer.

    I have lost hundreds of people in my life to overdose. I have lost dozens of people in my life to AIDS. If it wasn’t for this loving community of dedicated harm reductionists, I probably would’ve succumbed to my despair long ago. As we move forward—even slowly—I am grateful for the communities we have built.



    Photograph by Supercarwaar via Wikimedia Commons/Creative Commons 4.0

    • Tracey is an activist, advocate, writer, public health professional and mother. She lives in the San Francisco Bay Area.

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